Urban Youth Impact: Volunteer Application

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Carefully read and answer all questions. Some of the requested information is necessary for background screening. (Date of birth and social security number will only be used for background screening purposes)

*Please notify Urban Youth Impact if any of the following information changes*

Personal Data

First Name

Middle Name

Last Name

Nickname

T-Shirt Size

Sex

Date Of Birth

MM/DD/YYYY

Cell Phone Number

Email Address

How did you find out about Urban Youth Impact?

Address

Street

Add Apt. # On Second Line

City

State

Zip Code

Would you like to be added to our mailing list?

Emergency Contact

Emergency Contact First Name

Emergency Contact Last Name

Relationship

Emergency Contact Phone Number

THIS INFORMATION IS KEPT CONFIDENTIAL

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Health and Wellness

Please list any allergies

List any health problems or medical conditions that may affect your experience at Urban Youth Impact

Background Information

According to Florida Law, depending on the volunteer position, volunteers having access to children must be background screened. We may check your driver's license record, civil litigation, criminal background, and credit history.

Social Security Number:

Are you a Florida Resident?

How long have you lived in Florida?

Are you currently awaiting trial, sentencing or other disposition of a criminal charge?

Have you ever been convicted* of, or plead guilty or nolo contendere, or no contest to a crime?

If the answer to either question is yes, please explain (state the date, type of crime, place of occurrence, and disposition)

*Note: Conviction of a crime will not necessarily disqualify you for a volunteer position. Each conviction will be judged on its own merit with respect to time and job relatedness.

Adult Volunteer Agreement

I give consent to Urban Youth Impact to perform a background check

YesNo

I agree to meet with the Volunteer Coordinator for an interview

YesNo

I agree to attend one volunteer orientation

YesNo

I understand that misconduct and/or repeated absenteeism without prior notification will result in an immediate dismissal from the program. Under penalties of perjury, I declare that I have read the foregoing, and the facts alleged are true to the best of my knowledge and belief.

I permit Urban Youth Impact and any designates to photograph me, interview me, and/or make audio/video recordings of me. Urban Youth Impact may publish and disseminate the images for training, promotion, fundraising and other purposes via print, and/or electronic distribution via CD or web. I will not receive payment or any other compensation in connection with these images. I release Urban Youth Impact and its personnel from any and all liability which may or could arise from the taking, recording, publication, distribution or other use of these images.

I have read and understand the Volunteer Application. I agree to follow and comply with these guidelines. Should I have questions in regards to these guidelines, I know that the Volunteer Coordinator is available to answer any questions that I may have.

By participating as a volunteer I understand that I am making a commitment of service. My primary goal is to love, equip and empower the inner-youth and their parents for their God-given purpose. I will always put the children before myself. I will not intentionally do something that will jeopardize the safety of the children, staff or self.

I will not hold Urban Youth Impact of any other sponsoring or participating organization, church, or individual for any injury or illness that I incur from volunteering at Urban Youth Impact.

I have read and agree to the volunteer application requirements.

Full Name to act as signature